HCPro, JustCoding Inpatient - 2022 Issue 17 (April)
Record reviews: Finding what works for you
April 26th, 2022
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Article Overview
This article discusses practical approaches to chart and record review in CDI and HIM workflows. It compares two individual review styles, outlines broad steps used to assess clinical validity and coding accuracy, and describes how new CDI specialists are trained and supported during the learning process. The piece is intended for CDI specialists, auditors, HIM professionals, and coding staff who review claims and documentation.
Why This Topic Matters
Record review is central to documentation integrity, coding accuracy, and denial prevention. Understanding different review workflows can help teams improve consistency, training, and confidence without assuming one method fits everyone.
Article Sections
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Overview of record review approaches
Introduces the challenge of reviewing claims and documentation and explains that reviewers may use different methods to reach the same general goal.
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Siebert’s review process
Describes one reviewer’s broad approach to retrospective chart review, including the types of documentation she examines and the kinds of questions she asks during the review.
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Loos’ training process
Explains how new CDI specialists are introduced to chart review, how supervised practice is structured, and how ongoing support is provided during training.
What You Will Learn
- How chart review workflows can differ between CDI professionals
- What broad documentation elements may be examined during retrospective review
- How training and reconciliation are used when onboarding new CDI specialists
- Why note-taking and documentation of observations matter in the review process
Who Should Read This
- CDI specialists
- CDI auditors
- HIM professionals
- medical coders
- coding educators
- preceptors
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